Six years ago this month marks the anniversary of my first Newsletter. It wasn?t a real Newsletter, just a publicity blurb to draw attention to some articles I was writing for someone else?s website. It went out to all of about 10 people. The next week I included an opening essay and some short news items, and a funny thing happened ? a Newsletter was born. This emailing went out to a lot more people, and the immediate positive feedback I received changed my life. For the first time in years, I now had a reason for getting out of bed in the morning.

I am still in personal contact with many of the people who received my initial mailings, and I am constantly making new online friends from those of you who join my list. These are relationships I continue to value, as I strive to put your interests first in providing you with the very best service possible.

I can assure you that I have the best job in the world, though I do joke to people that being self-employed I have a real cheapskate for a boss. Which is where you come in.

I am committed to reaching everyone who needs this Newsletter, regardless of ability to pay. Fortunately, thanks to readers like you, I have been able to keep this Newsletter going as an independent service and not captive to any corporation, organization, or industry. My fund drive at the end of last year was a gratifying success, and I am looking forward to your support in my first fund drive of 2005.

By way of guidance, for a short while this was a paid subscription Newsletter, with subscriptions running at $29 regular, $10 hardship, and $100 group.

For the first time, as a small token of my appreciation, all donors will receive a handsome bookmark that says: "McMan ? Knowledge is Necessity."

Those who contribute $100 will receive an elegant retractable pen, laser-engraved in gold with none other than: "McMan - Knowledge is Necessity."

Those who contribute $250 will receive a handsome foam-insulated stainless steel coffee mug with a lid, your ideal commuting companion. Promise you will only drink decaf out of it. The cup proudly proclaims ? you guessed it - "McMan - Knowledge is Necessity."

To protect your privacy, the words depression and bipolar will not appear on the above items.

Those who wish to contribute $500 or more are in for a special treat: a sneak peak at a chapter from my book that is currently in the hands of a publisher. Donors will receive an autographed manuscript chapter, with my hand-inscribed ? I can?t contain myself - "McMan - Knowledge is Necessity."

Thanks to your past support, I have been able to devote myself fulltime to this Newsletter (and Website). This has resulted in exclusive reports on issues as diverse as treating hypomania, the mood spectrum, new drug discovery, treating bipolar kids, the fine points of brain science, depression in males, and what bipolar patients do to stay well.

This is "Knowledge is Necessity" in action. With your continued support, I am looking forward to many more Newsletters to come.

Special Feature: Last week?s Newsletter featured a series of articles on hypomania, which challenged how some psychiatrists are medicating this much-misunderstood phenomenon. This week, readers respond.

Also in this issue: Next week, Hypomanic Edge, McMan's Web, Donations.

Speaking Out

Angela (not her real name) writes:

"It was four in the morning. I was crouching in the bushes outside a hospital hiding from the campus police, explaining to a homeless man that I had more strength than he and would never allow him to take my cigarettes or my phone."

Angela had known for years that she was not like everyone else. Then the death of her husband of 32 years sent her into a tailspin. After seeking help, she was diagnosed with bipolar disorder. Says Angela:

"I went on shopping sprees almost daily, buying things I didn't need. I had always done that, but now more so. It made me happy and directed my mind somewhere else. I would stay up nights writing or studying, never could really sleep before, but now everyone said I was mentally ill and that was a symptom. I went on trips on a whim and yes, I had always done that, too. I gave away huge sums of money to my grown children because they asked and their father had treated with generosity, if not downright spoiling them. So there was another sign of my insanity. If I had dinner with several people and paid the tab, I was insane. If I talked, telling stories of my adventurous life, laughed for hours and hours with friends, then they said among themselves afterward that I was mad and in denial of my grief. That was the way I had been before, but now I was supposed to be different, you see."

Finally, after three years, her physician convinced her to take a mood stabilizer and an atypical antipsychotic. What happened?

"I couldn't function like myself. I didn't want to write poetry or stories in the middle of the night when the normal world was sleeping. I didn't want to laugh over conversations at long dinner parties or dance until the wee hours. Art projects I started were gathering dust (I have a BFA in painting). I couldn't even read. I would sit for hours in the same chair listening to jazz, smoking, which I had never done until my husband died. I wouldn't answer the phone. Didn't want to talk. So, okay, I take medication to appease people, then they are angry because I'm almost catatonic."

The meds sent her into a suicidal depression that resulted in a botched hospital admission. That?s how she found herself hiding in the shrubbery, arguing with a homeless person. She stopped taking her meds that night and started standing up for herself:

"I like who and what I am," she relates. "I shall have me be no other way. I am always high but in varying degrees. I bought a ticket to France two weeks ago at 3:00 in the morning, but always put them on hold now so I can cancel the next day. I get in my car and drive to other states just because I feel like it at that moment. I buy five dresses in a day just because I want to. You must understand that I can financially afford to do that and I never have remorse over my spending. I make love to my boyfriend in parking lots or on his office desk because we can't wait to get home to indulge. I will sometimes eat an entire box of chocolates in one day. I will read all night on a subject I'm interested in or putter in the studio till the sun comes up. I'm never tired, in great physical shape, an amazement to my doctor who has given up on medicating me."

Concludes Angela:

"I don't believe, based on my own experience, that hypomania is a condition which should be controlled by medication in most cases. I realize there must be some people who are victims of their disorder and it should be tempered. In my own case, talking therapy has sufficed."

Some Background

Angela was responding to last week?s Newsletter feature on hypomania, based on an interview with John Gartner PhD, a clinical psychologist at Johns Hopkins and author of "The Hypomanic Edge: The Link Between (a Little) Craziness and (a Lot of) Success in America.."

In the interview, Dr Gartner stated: "When psychiatrists become aware that the patient has hypomanic symptoms, then I think their tendency is to over-react, react as if it is the same as mania, which it is not in terms of the risk and the danger."

Some people can obviously benefit from medication, but Dr Gartner talked of the equivalent to microsurgery involving careful microadjustments "to take the edge off of the edge." This involves doctor and patient gradually inching toward that vital "sweet spot" that feels right to the patient.

Unfortunately, he said, psychiatrists trained to treat severe mania tend to overshoot, prescribing high doses based on clinical trials involving bipolar I patients. This often results in depression, weight gain, loss of libido, and cognitive dulling. Frustrated patients wind up quitting on their meds, sometimes with disastrous consequences.

Last week?s Newsletter has been uploaded onto McMan?s Depression and Bipolar Web in the form of an article, Treating Hypomania.

Dr Gartner?s comments clearly struck a chord with readers. Following are their responses:

Not Getting It

Louise writes:

I also wanted to make a comment on psychiatrists not "getting it". I had a psychiatrist for five years and was hoping, somehow, that things would get better. I was at the point of considering disability when I finally decided enough was enough. I?m not saying he didn?t listen to me, but he just didn?t get that my constant hypomania didn?t have to be thwarted with 900 mg of lithium or 7.5 mg of Zyprexa. These meds worked short-term, for severe manic episodes, but they weren?t meant for long-term therapy at those levels.

I?m a proofreader by trade so you can only imagine coming to work everyday and trying to function in a stupor. I finally found a new psychiatrist willing to try Lamictal for the second time. This is the most stable I?ve been in years! I guess sometimes you need someone with a new perspective to give you new options, and a new lease on life.

Must Be Able to Listen

Amelia writes:

Since mania and hypomania appear to be two different animals, it would make sense that the care and feeding would be different for each. I will be looking forward to learning more about hypomania.

As far as feeling my psychiatrist "doesn't listen" or doesn't "get it," I now have one who does, but I did see one recently who did not and would not even try. We often hear how patients mess up, how they do not participate effectively in their own treatment, or how they are not meds compliant, but given experiences I have had with doctors who seem to need total control, I have to wonder how often patients want to participate but are not allowed to. I mean, if I am to eat the pills, should I not have a say in what they are?

After reading this Newsletter, I am even more certain that in order to receive effective treatment, I must be informed, observant, and not shy about speaking up. And my doc must be willing to listen and not afraid to try a different approach.

Thinks I?m in Denial

Shelley writes:

I went to my pdoc because I was depressed. Seriously depressed. Suicidally depressed. After running through those screening questions, he decided the periods of time when I thought I felt normal were really hypomania. To me, they are what I consider feeling normal. Maybe compared to the low side of life with depression, they look really high.

The episodes he cites as proof are overspending and hypersexuality. In my mind, those were things I did to make myself feel better when I was depressed. After attempting to make me take some of the heavy hitters (his favorite being Risperdal), we finally agreed to add Lamictal to the Wellbutrin. I still don't think I need the Lamictal, but it was a compromise. He does listen to me, but thinks I'm in denial about my illness. I'm sure I'll quit the Lamictal someday. I don't believe doctors have any magic insight to our illness. They generally seem to push whatever pills they have samples of.

Unable to Feel

Therese writes:

I am sure my psychiatrist is afraid to let me "feel" anything. I have been flat since I began the regime of meds she put me on in Dec 2004, after being hospitalized for depression and diagnosed with bipolar I "because it runs in the family," if that is a legitimate method of diagnosis.

I do not cry for no reason any more, nor have nightmares about my profession. But I have no energy, sleep far too much, have no motivation to do anything, have not made a meal, feel no sadness (my husband has been diagnosed with cancer in the interim, and mother has had a life-threatening bout of flash pulmonary edema), no happiness. I do not know what has happened to "me". I used to be able to tie into something of interest and enjoy doing it just for the entertainment of having achieved getting the project done. Now I have no interest in beginning it.

Why Treat?

Sandra writes:

It seems odd to me that anyone would want to treat the mild hypomania that I've experienced. It doesn't cause me problems; rather it gives me a chance to catch up on my work and my life after a period of depression. To be fair and honest, my partner does complain about my irritability when I'm in this condition.

It seems to me that the only reason to treat this condition would be to stop the cycling that inevitably leads to depression. I wish someone would do a study on whether any meds besides Lamictal are effective at stopping depressive cycling without mania.

Free At Last

Claire writes:

I take only one medication: one mg of klonopin before bed. I have loads of energy, but it's not hypomanic energy. It's just regular energy. Long story short, being on lithium suppressed my feelings of being in the world - and now I feel I'm truly here, truly alive, feeling my feelings, feeling life in all its glory. I'm just always in a good mood!

Normal or Hypo?

Bill writes:

I have had one major depressive episode a couple of years ago (out of work for 10 weeks), and thought another was coming on a few months ago. Jury's still out. However, I can remember that I have had maybe 3, 4, or 5 days in the last 10 years where I felt "absurdly and inexplicably normal" from sun-up to bedtime. I had energy, I could get things done, I wasn't snapping at my wife or kids, not napping the day away, etc. I felt GOOD (despite other chronic illnesses), like I used to feel. Trouble is, it has been so long since "normal" went away that it's hard to recognize it.

So were these days just "temporary spontaneous remissions" or "hypomanic episodes"? No clue. Sure wish I could bottle that, though.

Why Take Meds?

Christine writes:

I definitely believe that doctors need to closely evaluate each patient before dosing them with a slew of medications. Even if the medicines do not hurt the patient, if they do not help (and we know about the major side effects they can cause), why take them?

Not Out of Control

Muriel writes:

I don't feel out of control when hypo, just on top of the world, like I can get it all done just right, not shy, not afraid but not out of control, not stupid crazy. Just ME!! Why would that ever be a bad thing? Anything less feels depressing to me. Every one else?s normal is my depression. Doctors don't seem to understand that the box they think I should be in emotionally doesn't fit me. I am always sad in that box they try to medicate me into. So I always stop the meds and try to balance by myself.

Better Existence Than This

Raylene writes:

I fear I have lost track of what exactly "feeling like myself" is. I've become unable to communicate this vague state of dysfunctionality to my doctor who I don't feel has any interest in "rocking" what he sees as a stable "boat". All I know is that a goal of "not getting hypomanic anymore" is not enough. I may not feel hypomanic but I don't feel anything else either. I feel nothing. Certainly there is a better existence than this.

Perhaps your article on the subject will prompt me to try again to work with this doctor to obtain a better result.

Watch the Sugar

Ellen writes:

My therapist told me that I am hypomanic and all that I have read makes me think that is just who I am. I am just that way. It's not a disease or something to be treated because I am happy all the time. But sometimes that happiness turns in a flash to supreme impulsiveness or almost as though I am on drugs - spaced out, in the moment right where I am.

I have found that the impulsiveness and scary part is better controlled if I have no sugar at all.

Part of a Team

Lest this Newsletter come across as inciting a rebellion against psychiatrists, one patient informed this writer that her psychiatrist had forwarded last week?s Newsletter to her. And Rebecca writes:

Basically, I feel like a very important part of two-person team - psychiatrist and patient. When I'm well and stable, we work really well together, so I trust that if I'm ever in a place again where I'm not able to make joint decisions he will make the right judgments on my behalf. It's taken time to get to this place.

Not All It?s Cracked Up To Be

Anonymous reminds us:

There are many patients whose "hypomanic" phases are an extreme and very negative experience. As noted by Dr. Jamison, mania can be negative as often as it is positive. The "racing thoughts" can have a very negative focus, especially self-criticism. The high energy can be experienced as a severe agitation, to the point where people feel they must pace the floor for hours at a time. Sleep problems can show up as insomnia: an inability to sleep, rather than decreased need.

Not Part of True Identity

Lynn concurs:

My own experiences with hypomania seem to be different from many people with bipolar. I do not get happy in the slightest to see hypomania arrive on my doorstep. For me, it brings out behavior that I later regret. I can't shut my mouth when it is needed, my spending habits increase, I feel sexual in an inappropriate way, and I get sudden impulses to drink, and to flamboyantly commit suicide. My hypomania perhaps is less mild than others, and closer to actual mania. I do not just get an elevated mood without bad consequences.

Therefore I definitely do not relate to hypomania as my true identity. It is something I want to stop immediately when it happens.

My current psychiatrist has been wonderful. She trusts that I know my cycles better than she does at this point, and so with her help and my own knowledge I have been able to successfully control my spring hypomanic episode. I would not trade my psychiatrist for the world for putting so much trust in me, and allowing me to have a say in the medications.

Hypomania is dangerous to me, and so I assume it is dangerous also to others. I do hope that more psychiatrists will put an emphasis on recognizing this phase. I never understood the questionnaires given to patients asking them how they feel, because many hypomanic people will say they feel great. More research needs to be done in how to recognize this phase and treat it.

Favors Medication

And Denise shares similar views:

As Kay Jamison says, it obviously carries some sort of evolutionary advantage, or it would have been bred out of the population by now. I lean to those who say the condition is both a blessing and a curse, and that it shouldn't even be called a "disease" but an anomaly. As an activist and advocate, that is the stance I have publicly taken. I guess my main reason for doing so is to reduce the internal stigma of "consumers" and their families. Having lived through several severe episodes on the part of husband and both sons, I'm very aware of how destructive full blown bipolar can be, and I would still not argue in favor of complete elimination of the condition from the gene pool. I do, however strongly favor medication and self-management.

Treating Hamilton

Dr Gartner?s book, "The Hypomanic Edge," featured founding father Alexander Hamilton as one of its case studies. Hamilton?s preternatural imagination and brilliance saved a young nation from bankruptcy, but his reckless disregard for his own safety wound up costing him his life in a duel.

This led to my posing this question to psychiatrists in last week?s Newsletter: If Alexander Hamilton were your patient, how would you treat him? Is this the same standard you apply to your other patients?

One psychiatrist was brave enough to answer. S Nassir Ghaemi MD MPH of Harvard and author or co-author of more than 60 articles writes:

On the question about Hamilton, I agree that I would not treat him if I could avoid it. I have suggested the same about depression though: I would not want to treat Lincoln's chronic depression or Washington's slow-thinking introversion. On the other hand, there was a time when Lincoln was severely suicidally depressed, and he in fact sought and received psychiatric treatment. There is a great book on the topic to be published later this year by Joshua Wolf Shenk called Lincoln's Melancholia.

Europeans are Proud to be Crazy, Too

Dr Gartner?s book attributed American success to a generous supply of mania lite genes inherited from the people mad enough to set off in leaky boats for an uncertain life on a strange shore. Dr Gartner observed that Europeans are mystified by American excess, even as they embrace our culture. This prompted a reply from Dr Marlies ter Borg, a self-described bipolar II philosopher. Dr ter Borg has published a book in the Netherlands on bipolar disorder and creativity from a European perspective, "The Flower of Sickness," which is being translated into English. Writes Dr ter Borg:

Actually we love American exuberance. What does dismay us is your provincial arrogance, possibly due to a deep rooted inferiority complex?

Of course you must be aware of the fact that the positive side of bipolar disorder was discovered by the Greek Philosopher Aristotle as early as the fourth century BC.

Many if not all great religious leaders, - David, Saint Paul, Augustine, Luther and of course Mohammed, and even Buddha, could in retrospect be labeled as bipolar- not to mention great writers/ poets/artists such as Goethe, Pushkin, Baudelaire , Van Gogh etc.

Of course those colonizing foreign parts in past centuries were also often a bit hypomanic. However in most countries such as former Dutch colony of Indonesia, they were kicked out by the locals. Do I need to explain why this didn't happen in the S?

Come on guys, let?s not exaggerate the nationalist sentiment, an outdated product from the 19th century hypomanic romanticism. These issues are worldwide.

We, and here I mean mankind, wherever, have centuries experience of how we should get the best out of hypomania without falling prey to destructive extremes.

Last Word

Finally, these insights from Anne:

Perhaps it was hypomania speaking when I told my family doctor, pychiatrist, psychologist, and neurologist that I would not take anything that made me fat or made it difficult to function. Perhaps it was the psych nurse in me that knew I couldn't work and drool at the same time. Perhaps it was the safety of knowing that in spite of a lifetime of experiencing hypomania as a difficult child, epileptic, person with multiple sclerosis, all of that got thrown away for the sake of my new label bipolar.

Perhaps it was the safety of knowing that I never was hospitalized, never attempted suicide, was capable of honors work in 4 majors, raised a son with bipolar who never attempted suicide, went to jail, or was hospitalized, and another who was just simply healthy.

Now I work in my job, and work in reforming the mental health system in our community as a board member. I have not been secretive about my label. Perhaps this is due to my hyperverbal nature. Yet indeed I have done some bold, dangerous, and uncharacteristic things in my life, yet survived my impulsivity, disorganization, hallucinations, and depressed, manic, or mixed states by learning to discipline my mouth, wait until after work to let myself lose it, and rather creative excuses for my giddy behaviors

When my desire is strong enough to overcome tedium, I achieve. It is rarely motivation that is the issue. I can do anything if I can tolerate the snail?s pace for a while. Truly I can relate to the "time warping" factor of the cycles, and have learned when to use them best to accomplish my dreams. I can write 10 pages of a proposal in two hours, and spend the rest of the day writing a paragraph.

Perhaps not everyone has this luxury, as my psychosis has not been particularly disabling, in fact on the contrary. It has been pleasant, comforting, inspiring, and occasionally a bit of an annoyance when I'm trying to sleep or drive and have to pull over. Perhaps that's the difference. I'm not generally so delusional that I can't figure out when to take time out and appreciate the show.

Buy The Hypomanic Edge

This book was as fun to read as "The Da Vinci Code" and far more accurate. Readers can support this Newsletter by buying The Hypomanic Edge: The Link Between (a Little) Craziness and (a Lot of) Success in America from Amazon.com by clicking the link.

Next Week

I?m on my way to the American Psychiatric Association annual meeting in Atlanta, where I?ll be taking lots of notes and reporting back to you. Till then ?

McMan's Web

Check out nearly 300 articles on all aspects of depression and bipolar, plus a bookstore, readers' forum, message boards, and other features at:http://www.mcmanweb.com (http://www.mcmanweb.com)

Lead Stories: The DSM and the depression literature may be silent on apathy, but that doesn?t mean you shouldn?t care.

Also in this issue: PsychiatryOnline, Win a McMan pen, Special brain stimulation feature (including ECT, rTMS, MST, VNS, and deep brain stimulation), Definitive new stats on mood, Help for vets, Goodwin and Jamison?s next edition, Next week, McMan's Web, Donations.

Apathy Matters

You know what it?s like. Someone has seemingly pulled the plug and the power drains out. Your get up and go just got up and went. Life, the universe, everything ? nothing matters as you shuffle through the clutter on the floor and flop into an unmade bed, your only refuge in a world you have given up on, that has seemingly given up on you.

Apathy is also used to describe indifference, such as to politics or NASCAR racing, but in a psychological context we are talking more like the opposite of motivation, the lack of will to go on and the inability to care about the consequences.

So is apathy part of depression? The DSM is virtually silent on the topic, as is the depression literature. Depression is generally characterized by too much emotion, but the DSM implicitly acknowledges we can experience too little. One of the two major depression symptoms is loss of interest or pleasure, such as in a hobby. Basically, we stop caring.

What?s missing here is that lack of caring doesn?t necessarily stop at pleasure. We can also become desensitized to grief or to something bad happening, but we?re not likely to see psychiatry weigh in on this any time soon.

The people doing the actual talking are the neuropsychiatrists, and they?re not giving depression any respect. In a groundbreaking article in the Summer 1991 Journal of Neuropsychiatry and Clinical Neurosciences, Robert Marin MD of the University of Pittsburgh argued that it is illogical that depressed people, who experience emotional pain, can suffer from a state of mind that is characterized by a lack of emotion.

Martiin Levy MD of UCLA is even more blunt. "Apathy is Not Depression," he and his colleagues assert in bold in the title of an article in the Summer 1998 Journal of Clinical Neuropsychiatry.

Dr Marin and other neuropsychiatrists perceive apathy in the context of brain damage rather than as a sign of emotional distress or cognitive impairment. They see apathy as the result of neuropsychiatric illnesses such as Alzheimer?s, dementia, Parkinson's, or Huntington?s, or else an event such as a stroke, involving disruptions to frontal-subcortical pathways that are fueled by dopamine and acetylcholine

Dr Marin would like to see apathy regarded as a syndrome (sort of like an illness). He also views apathy as a symptom when it is associated with the likes of Alzheimer?s. There is already a precedent in sleep, which constitutes a number of DSM disorders, as well as being listed as a symptom for depression and mania.

Can Dr Marin?s views be reconciled to depression? Yes, when the lack of caring factor is taken into account. In this context, apathy would be a symptom of depression. As a separate entity, it could be that apathy co-occurs with depression, much like anxiety and depression hook up as the Bonnie and Clyde of the brain. One can even make a case for apathy-driven depression.

Obviously there?s much to discuss, but first psychiatry needs to join the conversation.

Caring About Apathy

Clearly apathy and depression are related. A review article by Robert van Reekum MD et al of the University of Toronto in the Winter 2005 Journal of Neuropsychiatry reports on studies that found both apathy and depression endemic in populations with neuropsychiatric diseases and brain damage. Few were just one or the other. Depression and apathy were a package deal.

In a poster presented at the 2000 American Psychiatric Association?s annual meeting, Robert Morton MD et al of the University of Oklahoma reported on their study that examined 126 depressed or bipolar outpatients for apathy. They found that 79 percent met Dr Marin?s criteria for this state of mind.

Certainly, apathy rates a mention in a future DSM, if for no other reason than to put on notice the people who treat us. At the 2005 American Neuropsychiatric Association annual meeting, James Duffy MD of the University of Connecticut urged its inclusion in the next edition. "Patients who are apathetic do not take care of themselves as well as patients who are not apathetic," he argued. But he was talking in the context of neuropsychiatric illnesses.

So far, apathy has no champion from the depression quarter. To make matters worse, Dr Duffy?s debating opponent turned out to be Michael First MD of Columbia University. Dr First is editor of the current DSM, which is as good an indication as any that apathy won?t make it into the next one.

But you need not sit helpless waiting for psychiatry to get its act together. Whether apathy is part of depression or not, there are tests to tease it out, which is all that counts. The Apathy Evaluation Scale, devised by Dr Marin, asks questions such as whether you like to see a job through to the end and whether you need to be told what to do, and so on. Feel free to ask your psychiatrist to administer it to you.

Small studies and clinical experience have found that apathetic patients have responded to meds that activate dopamine and/or enhance what is called cholinergic function (vital to cognition). These include: Symmetrel and Parlodel (for Parkinson?s), Aricept and Exelon (for Alzheimer?s), amphetamine, Wellbutrin, Ritalin, and selegiline (an MAOI for Parkinson?s). In the development pipeline are a new generation of dopamine agonists.

Now for the yellow caution flag: Many of the above meds represent clear and present dangers for certain patients, and may not be appropriate. None except Wellbutrin and selegiline have been extensively tested on depressed populations and certainly not with apathy in mind. Dr Marin would like to see apathy as a new domain of psychiatry. But it is an uncharted territory, especially when depression is involved. Watch out for quicksand.

PsychiatryOnline

The above feature on apathy stems from a complimentary subscription to a service called PsychiatryOnline, put out by the American Psychiatric Association. PsychiatryOnline features the DSM-IV and Differential Diagnosis Handbook, Textbook of Clinical Psychiatry, APA Practice Guidelines, five APA journals, and an index and search function, all cross-linked and constantly updated.

A full text article in the Journal of Neuropsychiatry on apathy got my attention and started me on my way, including to several more full text articles on PsychiatryOnline.

You can check out a demo of PsychiatryOnline here.

The Gift of Giving

Last week I sent out my first Special Appeal by separate email. This Newsletter is a free service supported entirely by reader donations. This time around, in my first fund drive of 2005, all donors will receive a handsome bookmark that says: "McMan ? Knowledge is Necessity." Special gifts are available to those wishing to make a large donation, including "McMan ? Knowledge is Necessity" pens and mugs, guaranteed to change your life. Please take the time to search your inbox for "Special Appeal" and read the contents. Another Special Appeal will be on its way very soon. Donation information is provided in the Special Appeal and at the end of this Newsletter. Now back to regular programming ?

ECT is Changing, Says Expert

First the bad news about ECT. The cognition side effect that some patients experience can be persistent and profound, as opposed to merely transient as once thought, according to Harold Sackeim PhD of Columbia University, speaking at a symposium at the American Psychiatric Association annual meeting held in May,

The good news is that ECT is not the same as it was five years ago. "It is changing as we speak," he assured the gathering. This is largely due to changes in the width of the electrical pulse. Back in the old days of sine wave stimulation, characterized by a phase duration of 8.3 milliseconds, patients risked a massive reduction in cognitive performance, even at six months. Bilateral administration (with electrodes to both sides of the skull) was especially toxic.

The introduction of brief pulse stimulation in the 1980s greatly reduced but hardly eliminated risk of cognitive impairment and memory loss. Standard pulse width is between 0.5 and 2 milliseconds.

A new generation of machines that produce an ultrabrief pulse (at phase durations that vary from 0.1 to 0.4 milliseconds) promises a kinder and gentler era. A very recent unpublished study found virtually no difference in memory loss between those on the new machines and the control group. The briefer pulses permit clinicians to calibrate lower seizure thresholds. Right unilateral ultrabrief ECT, said Dr Sackeim, "appears optimal."

A further refinement in the works is focal electrically applied seizure therapy (FEAST) that concentrates the seizure to the frontal right part of the brain without affecting areas involving memory and related functions.

Singing the Body Electric

At the same APA symposium, speakers discussed several more treatments involving brain stimulation ?

rTMS

A possible alternative to ECT could be repetitive transcranial magnetic stimulation (rTMS), described by Mark George MD of the University of South Carolina at the APA symposium as "tickling the cortex," but sending signals into the deeper regions.

A magnetic coil is placed over the patient?s scalp (specifically the left prefrontal cortex). The field passes unimpeded through the skull and induces an electrical current in the brain. There have been 62 published studies on 1,415 depressed patients showing "a reasonable effect size." Better results corresponded to longer courses, greater pulse intensity, and pulse quantity.

One manufacturer, Neuronetics, is completing a study involving 240 patients. The NIMH is engaging in a four-year trial with the same number of patients. One of the aims of the latter study is to find out where best to apply the stimulation. The left prefrontal cortex, Dr George acknowledged, is "a rule of thumb I literally pulled out of a hat."

The procedure is safe and noninvasive. However, rTMS can cause unintended seizures under the wrong conditions. Accordingly, the International Society for Transcranial Stimulation recommends the procedure be performed in a medical setting with patients continuously monitored. Some patients may experience headaches.

rTMS is an investigational procedure in the US and is not FDA-approved. The treatment is approved in Canada.

MST

An investigational treatment, magnetic seizure therapy, uses rTMS technology to induce seizures. The effect is much like ECT, but because the current passes through the skull unimpeded, Sarah Lisanby MD of Columbia University explained at the APA symposium, it allows for more precise targeting into the brain. The aim is to induce seizures that do not spread to the motor cortex, thus sparing the memory regions of the brain. A study on primates showed better memory after MST than electroshock. Human subjects reoriented themselves much quicker after MST than ECT and experienced less retrograde amnesia.

ECT had much better efficacy than MST in treating depression in academic settings, but was about the same in community settings. Dr Lisanby and her colleagues are currently experimenting with higher doses in primates.

VNS

Vagus nerve stimulation (VNS) has received a lot of attention, as the treatment is on the verge of being granted an FDA indication for depression in treatment-resistant patients. The treatment is approved for epilepsy. In Canada the treatment is approved for depression.

A pacemaker-like device is implanted in the chest that sends a current up a wire attached to the vagus nerve at the base of the skull. From there, various pathways into the brain are activated.

The treatment is not without controversy. A major 12-week double blind study of patients still on their meds carried out by the manufacturer Cyberonics proved a disappointing failure. Rather than call it quits, Cyberonics kept the trial going as an open study and used as a comparison group patients receiving treatment as usual. After one year, 30 percent of the VNS patients responded to the treatment (or, to put it another way 70 percent failed to respond).

Cyberonics succeeded in convincing an FDA panel that 30 percent was an excellent result in light of the fact that this was a severely depressed population that had failed on all other treatments. Despite concern about the underwhelming response and the nature of the trial, the panel greenlighted the treatment for approval, with conditions. The FDA, however, rejected the panel?s recommendation, then later reversed itself on receiving more data from Cyberonics, granting "approvable" status, one step short of "approved." One public interest group is urging that the FDA back away from final approval.

Lauren Marangell MD of Baylor University at the APA symposium quoted Dr George in calling the vagus "the superhighway into the brain." She ruled out that the patients in the study could have improved over time as the result of the natural course of their illness, as those in the treatment as usual group had much poorer responses. Also, any placebo effect tends to take place early in treatment and is generally a nonfactor over the long haul. The benefits of VNS, by contrast, accrue over time.

The surgery is performed on an outpatient basis. The dose can be adjusted in real time by passing a magnetic wand over the chest. This is performed in the clinician?s office. Patients can turn the device on or off at home. There are no major side effects other than hoarseness in some patients and occasional vocal hiccups.

Deep Brain Stimulation

A taste of the future was offered at the APA symposium by Benjamin Greenberg MD PhD of Brown University. Needle-like leads with four electrodes are inserted into targeted regions of the brain, guided by MRIs. An extension wire runs from each lead to one or more VNS-like devices implanted in the chest. The treatment is FDA-approved for Parkinson?s, and is being investigated for OCD and depression. OCD patients reported changes in mood within two minutes of the device being switched on. A small pilot study on depressed patients had a similar effect. When the device was turned off or the battery failed, the patients got worse.

A 2005 study by Helen Mayberg MD of Emory University identified Brodmann area 25 (not to be confused with Area 52) in the subgenual cingulate region. Four of six treatment-resistant patients remitted when the adjacent white matter was stimulated.

Deep brain stimulation may supplant cingulotomies and capsulotomies, surgeries that have been used for OCD and are being investigated for depression. Guided by brain scans, a "Gamma Knife" (beams of gamma radiation) cuts lesions in specific areas of the brain. Unlike deep brain stimulation, the surgery is irreversible.

Segue

And now for something completely different ?

Definitive New Stats on Mood

This month?s Archives of General Psychiatry features four articles with findings from the National Comorbidity Survey Replication, an update of the landmark National Comorbidity Survey conducted a decade ago. The NIMH was the principal underwriter of the survey, led by Ronald Kessler PhD of Harvard (who led the original survey). The survey involved face-to-face interviews with 9,280 US residents. Main points:

* The lifetime prevalence of mental illness was 46.4 percent; 27.7 percent had two or more lifetime disorders, and 17.3 percent had three or more. Anxiety was the most prevalent (28.8 percent), followed by impulse control (24.8 percent), mood (20.8 percent), and substance use (14.6 percent). * The mood breakdown was major depression 16.6 percent; dysthymia 2.5 percent; and bipolar I and II 3.9 percent. (The original Survey was based on the DSM-III-R, which did not recognize bipolar II. Instead that Survey found 1.6 percent of the population experienced mania.) * Half of all lifetime illnesses start by age 14 and three-quarters by age 24. Later onsets are mostly of co-occurring conditions. Median age of onset for anxiety is 11 years, and mood 30 years. Lifetime prevalence estimates are higher in recent cohorts. * Most people with lifetime disorders eventually make treatment contact, far more for mood (88-94 percent), but the delay for mood ranges from six to eight years. * Twelve-month prevalence for all disorders was 26.1 percent, and of these 22.3 percent were serious, 37.3 percent moderate, and 40.4 percent mild. Thirty percent of major depression cases were serious; as were 49.7 percent of dysthymia cases and 82.9 percent of those with bipolar I and II. * Fifty-five percent of the 12-month cases carried a single diagnosis, 22 percent two diagnoses; and 23 percent three or more. Anxiety led the pack at 18.1 percent; mood 9.5 percent; impulse control 8.9 percent; substance 3.8 percent. * Of the 12-month cases, 41.1 percent received some treatment in the past 12 months; 12.3 were treated by a psychiatrist, 16 percent by a mental health specialist such as a psychologist or social worker; 22.8 percent by a physician or nurse; 8.1 percent by a human services provider such as a spiritual advisor; and 6.8 percent by a complementary-alternative practitioner. Forty-five percent who saw a psychiatrist received minimally adequate care. Only 12.7 percent of those seeing a doctor or nurse received minimally adequate care. Seventeen percent of those who saw a spiritual advisor or a complementary-alternative professional received minimally adequate care.

The Cost of War

Gannett News reports that a US Senate committee is considering legislation to expand mental health care for veterans with serious mental illness. Twenty-eight percent of the 86,000 who have left the military and sought VA health care have been preliminarily diagnosed with mental disorders, according to the VA, including nearly 12,400 with possible PTSD. The VA is requesting $179 million for PTSD treatment, $93 million for readjustment counseling, $365 million for substance use programs, and $2.2 billion for serious mental illness care.

And Finally

Goodwin and Jamison?s second edition of the definitive book on bipolar disorder, "Manic-Depressive Illness," will be published sometime in 2007.

Next Week

I will be attending the Sixth International Conference on Bipolar Disorder, where I will be asking Dr Kessler of the National Comorbidity Survey Replication a lot of questions. I look forward to meeting many of you there.

McMan's Web

Check out nearly 300 articles on all aspects of depression and bipolar, plus a bookstore, readers' forum, message boards, and other features at:http://www.mcmanweb.com (http://www.mcmanweb.com)

You can support this Newsletter by clicking on any of the site's Amazon.com links to do your online buying, including items not listed on McMan.

Donations

My first fundraising drive of 2005 is in full swing. This Newsletter is a free service. If you would like to support this Newsletter, you can donate any amount you choose by by clicking on the PayPal button below:

Lead Stories: A major survey recognizes a significant population in need. But don't count on the DSM to let your psychiatrist know.

Also in this issue: The anxiety spectrum, Treatment, Sleep, Life before and after diagnosis, TIMA updates its algorithm, Replacement term for patients and consumers, Experimental meds, Old meds with new uses, Diagnostic insights, Acupuncture, Mood goes south in the north, Bipolar impairment, Readers respond to apathy-depression issue, Cruisin' for a bruisin' , Next week, McMan's Web, Donations.

Unipolar ? Bipolar Waiting to Happen?

If there is any story of the year thus far, it is most unequivocally the mood spectrum and where the various colors start blending at that contentious shade called hypomania. Never mind that the legendary diagnostician Emil Kraepelin was hip to the phenomenon nearly a century ago. Not only did he accurately describe mixed mood states and identify hypomania, but he declined to distinguish between unipolar depression and bipolar disorder. In recent years, psychiatry has been waking up to Kraepelin, and nowhere was this more evident than at the Sixth International Conference on Bipolar Disorder hosted by the Western Psychiatric Institute, held in Pittsburgh in the middle of this month.

At a major symposium devoted to the mood spectrum, Kathleen Merikangas PhD of the NIMH threw down the gauntlet by challenging "hypomania as a specifier for bipolar II." Dr Merikangas has been working with Jules Angst MD of the University of Zurich, the lead researcher of the groundbreaking Zurich Cohort Study that tracked patients from 1978 to 1999.

Dr Angst and colleagues used three criteria for bipolar II, the DSM-IV (which mandates at least three hypomanic symptoms, four if irritable, over at lest four days), a "strict" Zurich criteria (which lowered the symptom threshold to three over one day) and a "broad" criteria which dropped the symptom requirement to two over one day. Using the DSM criteria yielded a finding of 7.4 percent bipolar IIs in a depressed population. On the Zurich strict criteria, the figure shot up to 23.7, and for the broad criteria ? get ready ? 49.2 percent.

In other words, nearly half of a so-called unipolar population exhibited symptoms that were more than just unipolar.

Lest one write off these findings as typical of those wild and wacky Swiss, Ronald Kessler PhD of Harvard and lead researcher of the landmark National Comorbidity Survey from a decade ago parachuted into the symposium armed with new data published just days before.

Researchers from what is called the National Comorbidity Survey Replication conducted more than 9,000 face-to-face interviews. Using one measure, they determined that those with bipolar disorder comprise three percent of the US population, about evenly divided into Is and IIs, far higher than the previously estimated one or two percent. But they also polled for "subthreshold" bipolar, based on just two or three symptoms over four days. Including this population pushed the total percentage to 4.3. Dr Kessler confirmed that the figure would have been higher had they dispensed with the DSM four-day rule.

A different measure found only a 1.5 percent population of bipolar Is and IIs ? probably an underestimate, Dr Kessler acknowledged ? but the subthreshold population of 2.6 brought the total percentage to 3.9.

In data not yet published, Dr Kessler revealed that 70 percent of bipolar Is, 68 percent of bipolar IIs, and 63 percent of those with subthreshold symptoms reported major impairment. Those in the subthreshold group reported nearly the same number of days out of work as bipolar Is (43 to 44 vs 47 for bipolar IIs).

"These subthreshold people without bipolar sure have something," Dr Kessler told the conference.

Ironically, Dr Kessler pointed out, the next DSM is likely to tighten rather than broaden the criteria for bipolar. It took a good 20 years to get bipolar II into the current edition, such is the pace of change. Clearly bipolar III or some other type of recognition is in for an equally long wait at best. Are all you difficult-to-treat unipolars happy with that?

Why Understanding the Mood Spectrum is Critical

At the same symposium, Giovanni Cassano MD of the University of Pisa and head of an international consortium known as the Spectrum Project reported that only 50 percent of unipolar patients "can be described as free from a manic component." He referred to a study he and his colleagues published the previous year (and cited in three previous Newsletters). In that study, recurrent unipolar patients reported a substantial number of manic or hypomanic symptoms (from a very long list). The most common symptoms (starting from the top at 67.5 percent and descending to 50.4 percent) were: persistently good or high mood, irritability, vigorous and full of energy, sensitive to harmony in nature, easily distractible, and impatient.

Patients with a higher number of manic/hypomanic symptoms also had more depressed symptoms. This also applied to bipolar I patients. And perhaps most significant, in the group with unipolar depression one manic/hypomanic symptom increased the likelihood of suicidal ideation by 4.2 percent. For a patient with 10 symptoms, this equated to a 42 percent increase in risk.

In their published article, Dr Cassano and his colleagues concluded that their findings supported "a continuous view of the mood spectrum as a unitary phenomenon," that unipolar and bipolar disorder should not be regarded as separate entities, and that mood fluctuations are common to both unipolar and bipolar disorder.

Last year, this writer sat down with Ellen Frank PhD of the University of Pittsburgh, one of the co-authors of the study and one of the organizers of this conference. Although she cautioned, "I don?t think we know yet whether [our findings] have treatment implications," she also said: "I think patients need to be aware of what might be softer expressions of both hypomania or mania, and try to the fullest extent possible to get their doctors to listen to their concerns that there may be something more going on here than unipolar depression."

Feeling Anxious

Dr Cassano also discussed anxiety in the spectrum. Working with preliminary data, he and his colleagues divided unipolar patients into Cluster 1 and Cluster 2 groups. The second cluster, comprising 34 percent of the sample, had a wide range of anxiety symptoms that turned up at least 80 percent of the time, including: obsessing over tasks, too embarrassed to speak or enter or leave a room during a meeting in progress, unsure before an exam, feeling confused, worried over disapproval, more comfortable in small groups, unable to say no, need to be comforted and reassured, unable to make a decision, overcritical of self or others, suddenly sweating, heart pounding, flushes, anxious under stress, and reluctant to do something out of fear it won?t work out.

Dr Cassano pointed to two studies by his collaborator, Dr Frank, which found longer times to remission in unipolar and bipolar patients with panic symptoms.

Treatment Issues

Dr Kessler in his talk also discussed treatment. Compared to 10 years ago when the original National Comorbidity Survey was published, he said, people are much more likely to acknowledge they have a problem and that treatment works. The shame and embarrassment about mental illness has gone down.

There has been a two-third increase for treating mental health problems in the US, most in the primary care sector. Unfortunately, patients would just like to take a pill and not talk about their illness, he said. Less than one-third of people treated for mental health are getting adequate treatment. Many drop out (mainly from primary care) before they receive an adequate course and care.

"We see lots of people taking the first step," Dr Kessler concluded, "but they?re not there yet. I hope the next survey will show people sticking with treatment."

Getting Sleep Right

This Newsletter has featured a number of stories on interpersonal social rhythm therapy (IPSRT). The therapy was developed by Dr Frank from interpersonal therapy and is designed to help bipolar patients regularize their daily routines and their sleep so they can get a handle on their illness. Disrupted sleep is to mood what killer bees are to a nice quiet day in the garden. At the Bipolar Conference, Dr Frank announced the results of a study in press. In that study, patients were divided into groups receiving either IPSRT or intensive clinical management (which focuses on education).

At first blush, there was little difference in outcome between the two groups, but further analysis revealed that those with high levels of co-occurring medical ills fared better on the intensive clinical management (which zeroes in on coping with physical complaints) while the medically healthier individuals responded better to IPRST (which emphasizes cultivating personal and social skills).

Grand Canyon

In her talk, Dr Frank made the observation that people with bipolar disorder tend to divide their life in two ? before diagnosis and after diagnosis. It would be helpful, she suggested, if patients were able to grieve for the loss of their healthy selves.

Treatment Algorithm Update

At the Conference, the Texas Implementation of Medication Algorithms (TIMA), with an all-star panel headed up by Trisha Suppes MD of the University of Texas Dallas, presented a sneak peek of its updated bipolar I algorithm. A quick rundown:

Acute (initial phase) mania: The 2002 algorithm recommended just three meds as first options for euphoric mania: lithium, Depakote, or Zyprexa. The new algorithm also includes Abilify, Risperdal, and Seroquel as first choices.

The previous algorithm recommended either Depakote or Zyprexa for mixed mania. The new edition includes Abilify and Risperdal.

Like the previous algorithm, monotherapy is the recommended first treatment. Stage two and three recommend two-meds combinations and stage four suggests going with ECT or three meds.

Acute bipolar depression: Lamictal with or without another mood stabilizer is the first choice. This contrasts with the earlier algorithm that emphasized stabilizing the patient before treating the depression. Stage two recommends Seroquel or Symbyax monotherapy while stage three suggests various combinations. Only at stage four is an antidepressant (with an antimania agent) considered. This is in sharp contrast to the previous algorithm that introduced antidepressants at stage two.

Maintenance phase mania: The previous TIMA algorithm was exceptionally vague in its recommendations for maintenance (long term) treatment. The new algorithm recommends lithium, Depakote, or Lamictal, or ? with reservations that relate to safety issues ? Zyprexa. More meds are introduced at succeeding levels. Significantly, TIMA does not recommend combination therapy for maintenance phase mania.

Maintenance phase depression: Lamictal with or without a mood stabilizer at first instance, lithium at second, an antimanic agent with an antidepressant (including Symbyax) at third, and introducing Depakote, Tegretol, Trileptal, the rest of the antipsychotics and ECT as fourth and fifth options.

As with its previous algorithm, TIMA had no recommendations for treating bipolar II or rapid cycling, but did promise to give these matters its attention as knowledge became available.

What?s in a Name?

Patients or consumers? Both fail to do the trick. At a Meet the Doctor session at the Bipolar Conference, a member of the audience prefaced her question with this introduction: "I?m an end-user."

Perfect.

Posters

The Bipolar Conference featured a wealth of outstanding posters. Following is the first installment of the many that caught my eye ?

Experimental Meds

* A Macon (GA) Psychiatry Center chart review of 39 patients on the novel anticonvulsant Keppra (levetriacetam) found a good response for mania when used in modest doses adjunctively. Thirty-one patients reported no adverse events. Eight reported mild sedation or mild drowsiness. * Valdoxan (agomelatine) is a "melatoninergic agonist" that also blocks serotonin 2C receptors. The drug is being tested as an antidepressant and sleep agent. In an open study, 81 percent of 21 severely depressed bipolar I patients responded to adjunctive use of the drug after six weeks. Forty-eight percent responded after one week. * Requip (ropinirol) is a dopamine agonist used to treat Parkinson?s. An Italian pilot study of 12 patients with treatment-resistant depression (five with bipolar) found five responded to adjunctive use of the drug. * Rilutek (riluzole) is a glutamate inhibitor used to treat ALS. An NIMH pilot study of 14 patients found combination lithium and riluzole "showed a significant treatment effect" for bipolar depression

Old Meds, New Use

* Equetro is the trade name for extended release carbamazepine. The old form of carbamazepine goes by the trade name Tegretol. Though used extensively for treating mania, manufacturer Novartis never sponsored any major trials on bipolar patients. Shire conducted the mania trials for Equetro and recently got FDA approval for mania. Now the company is looking at bipolar depression. Three studies have found "significant improvement" in depression scores. * A Harvard/George Washington University study of 26 patients with treatment-refractory bipolar depression found that Depakote worked as well as Lamictal, though both groups continued to experience moderate residual depression. Lamictal was better tolerated.

Diagnostic Insights

* Mania is not just mania. Hagop Akiskal MD?s research group surveyed 1,090 manic patients and discovered five major components: 1) Depression 2) Mania (you?re not seeing things ? it?s number two to depression even in mania) 3) Sleep difficulties 4) Psychomotor inhibition 5) Poor judgment-irritability. * Dr Akiskal?s group also challenged the DSM?s assumption of elevated mood being the primary feature of hypomania. In a survey of 197 bipolar II patients, the group found almost all the patients reported overactivity (goal-directed behavior) and less commonly elevated mood. The study?s authors noted that elevated mood corresponded with only two DSM-IV hypomanic symptoms. * A French survey of 156 bipolar patients and 42 controls suggests two types of bipolar depression, one characterized by virtually al systems shutting down that includes lack of emotional reaction, cognitive and motor slowing, loss of motivation, and decreased sensation. By contrast, the second type is more revved up, with no disturbance in motivation or sensation.

Acupuncture

A multi-center study of 26 patients receiving either acupuncture (with needles placed on "bipolar depression" points) and sham treatment (needles placed elsewhere) found similar significant improvement in both groups.

STEP-BD Findings

* An analysis of 1000 patients enrolled in the NIMH-underwritten STEP-BD found that patients from northern locales experienced significantly higher rates of depression than their southern neighbors. Depression rates for northerners peaked during the fall while summer was the worst time of year for people from the south. Bipolar Is fared better throughout the year than bipolar IIs. * An analysis of 500 STEP-BD patients found that one-third missed 11.5 of their prior 30 days at work. Severity of depression affected functioning and work disability.

Segue

Much more from the Sixth International Conference on Bipolar Disorder in weeks to come. Now for a few items ?

Mail Bag

Last issue raised the possibility of apathy as a feature of depression, but noted that the neuropsychiatrists who are doing all the talking consider it a neuropsychiatric phenomenon (such as a part of Alzheimer?s or Parkinson?s) rather than a characteristic of psychiatric illness. Colleen (her real name) writes:

And Depression isn't neuropyschiatric?

Then, will someone please let the pharmaceutical industry know so they can stop pummeling us with drugs that alter, change, thwart, or enhance our brain chemistry and neuropathways?

Pharmaceutical companies will be relieved to know that their expensive research and ubiquitous marketing are no longer needed. I am sure they will be willing to give up the meager profits they make on an illness that doesn't even exist, neuropsychiatrically that is. Think of the money they'd save by instead manufacturing a simple sugar-pill placebo rather than synthesizing all those pseudo-neurochemicals.

Imagine the egg on the FDA's face when they find out that Prozac/Paxil does not cause suicidality in depressives, because depression is not neuropsychiatric and therefore untreatable pharmacologically. All those people committing suicide (for whatever reason) are just plain sicko, not depressed. Phew!

John A Mozzer (he urged using his full name) takes a different view:

I don't see apathy as being part of the state of depression, ever. People with depression ruminate, catastrophize, and feel guilty, far too excessively to be considered apathetic in any respect. In fact, I've always been irked by the "loss of interest" description, so often on the top of the list of symptoms in media coverage, because it implies apathy.

In the scenario you describe, where one will "flop into an unmade bed", taking "refuge in a world you have given up on, that has seemingly given up on you," likely paralyzing hopelessness and helplessness goes with that, and worry about one's future is likely to be extreme. How can that be considered an example of an "inability to care about the consequences"?

When a depressed person complains of "lack of motivation", that likely goes with guilt about not being motivated, guilt about not getting done whatever the person feels he or she should be getting done. Otherwise, the person wouldn't complain about "lack of motivation". No hint of apathy there.

When a depressed person is no longer able to experience pleasure from formerly enjoyable activities, no longer able to enjoy friends, that is likely experienced as a tremendous loss. If the person actually didn't care, there would have to be no sense of loss. But the depressed person feels tremendous loss, and painfully cares.

I wish you would support my cause. Support getting rid of the "lack of interest" phrase from descriptions of depression. "Inability to experience pleasure," yes. "Lack of interest," no. But you're going in the opposite direction by stating, "clearly apathy and depression are related".

Cruisin? for a Bruisin?

He?s jumped on furniture on the Oprah show, made a spectacle out of himself at the Eiffel Tower, and nearly throttled a squirt gun-wielding prankster. He went ballistic at Today Show host Matt Lauer, berated Brooke Shields for making a personal health decision, and belongs to a cult whose founder believes we come from aliens.

Incredibly, he says it?s psychiatry that?s the pseudoscience. And he entertains delusions that he knows more about meds than the people who have tried them or the mothers who have seen their kids get better on them.

"There?s no such thing as a chemical imbalance," he proclaimed on the Today Show.

Meet pop gun Tom Cruise of Hollyweird. Ground Control to Major (pain in the butt) Tom, get help. Can you handle the truth?

Next Week

Lots of news and updates to report. Till then ?

McMan's Web

Check out nearly 300 articles on all aspects of depression and bipolar, plus a bookstore, readers' forum, message boards, and other features at:http://www.mcmanweb.com (http://www.mcmanweb.com)

You can support this Newsletter by clicking on any of the site's Amazon.com links to do your online buying, including items not listed on McMan.

Donations

My first fundraising drive of 2005 is in full swing. This Newsletter is a free service. If you would like to support this Newsletter, you can donate any amount you choose by by clicking on the PayPal button below: